4 Program Basics: When Functional limitation G codes will be submitted for the primary limitation: At the outset of the therapy episode At a minimum every 10 th visit At a formal re evaluation At discharge/ end reporting (unless the patient self discharges prior to formal discharge visit) A subsequent functional limitation may be reported if care continues to address the subsequent limitation after you end reporting of the primary limitation 7 Program Basics: How Therapists will use a valid and reliable assessment tool(s) and/or objective measure(s) in determination of the severity of the functional limitation Multiple tools may be used Therapist judgment may be used in the severity modifier determination in combination with data gathered Documentation of the G codes and the rationale for selection of severity must be included in the medical record 8 4

5 Reporting Timeline January 1 June 30, month testing period for functional limitation data submission July 1 December 31, 2013 Claims will be returned unpaid if functional information is missing 9 REPORTING DETAILS 10 5

6 Nonpayable G codes G codes are based on the International Classification of Functioning, Disability and Health (ICF) Functional limitation: activity limitations + participation restriction Specific categories plus an other category Therapist chooses the most appropriate category: Most clinically relevant to a successful outcome for the beneficiary; The one that would yield the quickest and/or greatest functional progress; OR The one that is the greatest priority for the beneficiary 11 Nonpayable G codes Choosing Other Defined by one of the four specific categories Therapy services are not intended to treat a functional limitation When an overall, composite or other score from a functional assessment tool (such as FOTO, etc.) is used and it does not clearly represent a functional limitation defined by one of the four code sets. Other PT/OT Subsequent Functional Limitation category is only selected after the Other PT/OT Primary Functional Limitation category has been reported on the beneficiary during the same episode of care. 12 6

9 Severity Modifiers 7 point scale Choosing the modifier: Reflects the score from a functional assessment tool or other performance measurement instrument. Combine the results of multiple measurement tools used during the evaluative process Clinical judgment in the assignment of the appropriate modifier. CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat (or address) a functional limitation 17 Severity Modifiers CY2013 Modifier Impairment Limitation Restriction CH CI CJ CK CL CM CN 0 percent impaired, limited or restricted At least 1 percent but less than 20 percent impaired, limited or restricted At least 20 percent but less than 40 percent impaired, limited or restricted At least 40 percent but less than 60 percent impaired, limited or restricted At least 60 percent but less than 80 percent impaired, limited or restricted At least 80 percent but less than 100 percent impaired, limited or restricted 100 percent impaired, limited or restricted 18 9

10 Reporting Frequency G codes are reported throughout care at specific intervals Report only on one limitation (primary) You may report on a second limitation but not simultaneously If a patient is seen for a second condition beyond the resolution of first then you will report a second (subsequent) limitation 19 Reporting Frequency Submission of 2 G codes at each reporting interval except: Therapy services under more than one therapy POC One time therapy visit. When a beneficiary is seen and future therapy services are either not medically indicated or are going to be furnished by another provider the clinician reports current status, goal status and discharge status on the claim 20 10

12 Claim Submission Functional limitation data is comprised of three pieces of information: G code Severity modifier Therapy modifier No required order for the modifiers No KX modifier Reported as a separate line item Nonpayable code $0.01 or $ Submission Acknowledgement Medicare will return a Claim Adjustment Reason Code 246 (This non payable code is for required reporting only.) and a Group Code of CO (Contractual Obligation) assigning financial liability to the provider. In addition, beneficiaries will be informed via Medicare Summary Notice 36.7 that they are not responsible for any charge amount associated with one of these G codes

15 Functional Data Requirements Determine primary functional limitation Select an appropriate functional assessment tool(s) or objective measure(s) Determine the category of the primary functional limitation Determine the severity of limitation Determine the projected goal Based on the current functional limitation status and other patient information Determine the projected goal Report the functional limitation data Current/ discharge status with severity modifier Projected goal with severity modifier 29 Scenario for Patient with LBP 65 y/o male 3 days s/p onset of acute low back pain (LBP) with (L) LE pain into posterior thigh to knee Second episode of this condition in the past 6 mo. Previous episode had no LE symptoms. Injury is not work related Comorbidities include hypertension controlled by medication Patient works for painting contractor. Has been on bed rest since onset 30 15

17 Determine Projected Goal Patient reports that his primary goal for PT is to return to work and prior function. He also wants to have the skills to prevent reoccurrence. They agreed upon a goal to return to prior function. The PT then has a goal of 0 on the Oswestry (CH modifier). G8979 CH 33 Initial Evaluation Functional Limitation Documentation Patient reports that his primary goal for PT is to return to work and prior function (G8978) with minimal help. His current impairment level is 20 to 40 percent impaired (CJ) based on his Oswestry score. He is expected to be achieve a score of 0 percent impaired (G8978 CH) after 12 therapy visits

18 Example of Charge form for Initial Evaluation visit th Visit Description The patient had been doing well and his Oswestry score had gone down to 11 his last visit. However, he went on a 6 hour car trip over the weekend and due to the weather he did not get out on a regular basis to perform his extension exercises. He reports he now again has occasional pain down his thigh. The patient s Oswestry Score is 42 today

19 10 th Visit Functional Measurement Data Oswestry Disability Index Test Key findings Score Severity translation 42 42% impaired; At least 40 but less than 60% impaired, limited or restricted CK modifier Functional limitation category Mobility: walking & moving around G8978 CK th Visit Documentation Patient reports that his primary goal for PT is to return to work and prior function (G8978) with minimal help. His current impairment level is 40 to 60 percent impaired (CK) based on his Oswestry score of 42. He is still expected to be achieve a score of 0 percent impaired (G8979 CH) after 12 therapy visits

20 Example of Charge Form for 10 th Visit 39 Discharge Visit Description Visit 12 Patient returns after 2 weeks for review and progression of his home exercise program and fitness program. He reports he has been performing his exercises and positioning routinely. He is symptom free and has returned to work without difficulty. The patient has reached the projected functional goal

25 Determine the Projected Goal Physical Therapy Prior to CVA lived in home w husband and was independent in ADLs and driving Goal is to return to this setting and prior activities Projected goal is at least 1 percent but less than 20 percent impaired, limited or restricted (CI modifier) G8979 CI Occupational Therapy Prior to CVA lived in home w husband and was independent in ADLs and driving Goal is to return to this setting and prior activities Projected goal is at least 1 percent but less than 20 percent impaired, limited or restricted (CI modifier) G8988 CI 49 Initial Evaluation Functional Limitation Documentation Physical Therapy Patient s primary goal for PT is to be able to walk outdoors with minimal help. Her current impairment level is 70% (G8978 CL) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She is expected to be able to walk outside her home with less than 20% (G8979 CI) impairment after 8 weeks of therapy. Occupational Therapy Patient s primary goal for OT is to be able to perform ADL s with minimal help. Her current impairment level is 54% (G8987 CK) based on her DASH score. She is expected to be able to perform her ADL s with less than 20% (G8988 CI) impairment after 8 weeks of therapy

26 Example of Charge Form for Initial Evaluation Visit th Visit Description The patient is happy with her progress She is able to walk with only close supervision now demonstrating slightly greater walking speed She still notes some decreased confidence walking outside Her balance is improved especially with single limb stance activities Her arm function has also improved and she is able to dress with minimal difficulty and perform ADL s more easily 52 26

28 10 th Visit Documentation Physical Therapy Patient has improved in safety with her mobility. Her current impairment level for walking around (G8978) is 40% (CK) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She is expected to be able to walk outside her home (G8979) with less than 20% (CI) impairment at time of discharge from physical therapy. Occupational Therapy Patient is better able to perform her ADL s. Her current impairment level for ADL s is 32% (G8987 CJ) based on her DASH score. She is expected to be able to perform her ADL s with less than 20% (G8988 CI) impairment at time of discharge from occupational therapy. 55 Example of Charge Form for 10 th Visit 56 28

30 Discharge Visit Functional Measurement Data DASH Test Key findings Score Severity translation Mild issues with ADL s percent limited: 10 percent limitation: At least 1 but less than 20 %impaired, limited or restricted CI modifier Functional limitation category Self Care: G8989 CI 59 Discharge Visit Documentation Physical Therapy Patient has improved in safety with her mobility. Her current impairment level for walking around (G8980) is 10% (CI) based on her OPTIMAL, Berg balance, and 4 meter walk scores. She has achieved her goal to be able to walk outside her home (G8979) with less than 20% (CI) impairment at time of discharge from physical therapy. Occupational Therapy Patient able to perform her ADL s with minimal difficulty. Her current impairment level for ADL s is 16% (G8989 CI) based on her DASH score. She has achieved her goal to perform her ADL s with less than 20% (G8988 CI) impairment and is discharged from occupational therapy

Carol Novak, RN, CHC Martin Yuson, DPT, JD Tips for Effective Auditing/Monitoring of Medicare Documentation for OT, PT and Speech 4/24/2013 The wonderful thing about standards is that there are so many

Risk Advanced Therapy Management The larger the risk the more incentive to actively change behavior to control costs and provide only those services that are medically necessary 3 Thoughts About Risk Medicare

New Outpatient Therapy Evaluation and Intervention E&I Codes An introduction to the new policy and new claims coding requirements Disclaimer Contents of this presentation are for educational purposes only.

Therapy Functional Reporting Part A Provider Outreach and Education March 2016 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in

ICD-10 IS COMING OCTOBER 1, 2014 WHAT IS THE IMPACT ON THERAPY PRACTICES? CHET DESHMUKH, MBA, OTR/L, CPC, CHDA Overview Understanding the language of clinical diagnosis What is ICD? About ICD-9 CM Good

Tom Ambury, PT, CHC Attendees will understand the key components of the initial evaluation Attendees will understand the importance of the initial evaluation in establishing the skilled need for therapy

Compliance TODAY October 2013 a publication of the health care compliance association www.hcca-info.org Why compliance matters to the enforcement community Loretta Lynch U.S. Attorney, Eastern District

Comprehensive EHR Infrastructure Across the Health Care System The goal of the Administration and the Department of Health and Human Services to achieve an infrastructure for interoperable electronic health

11 Part B Billing Scenarios for PTs and OTs The following billing scenarios formerly appeared on the Frequently Asked Questions (FAQ) website and on the Therapy Medlearn website as "11 FAQs" - posted 9/13/02

Making Medicare Work for Physical, Occupational and Speech Therapists Workshop Q&As This Question and Answer (Q&A) series was developed from the Making Medicare Work for Physical, Occupational and Speech

Medicare Skilled Home Health Overview July 9, 2015 COVERED MEDICARE HOME HEALTH SERVICES Per 1861 (m) of the Social Security Act, the following are covered Medicare home health services: Skilled nursing

Demystifying ICD 10 Beyond the Hype. What Therapists Should Know about ICD 10. Welcome This session will be recorded Link to the recording and resources will be emailed to all registrants Jim Plymale President

OASIS ITEM (M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total

NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES POLICY GUIDELINES Version 2015-1 Page 1 of 11 Table of Contents SECTION I REQUIREMENTS FOR PARTICIPATION IN MEDICAID 3 QUALIFIED PRACTITIONERS. 3

A Guidebook to the 2012 Physician Quality Reporting System Last Updated: February 2, 2012 Getting Started With PQRS The Patient Protection and Affordable Care Act made participation in Medicare s Physician

CPT Coding Update And Other Issues Robert E. Smith, M.D. Alison Lynch, M.D. November 13, 2013 1 Disclaimer This information is for educational and informational purposes only, and represents the understanding

Follow-up information from the November 12 provider training call Criteria I. Multiple Therapy Disciplines 1. Clarification regarding the use of group therapies in IRFs. Answer: CMS has not yet established

3 O0100 O-1 Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators. Surgical procedures include routine pre-

REPORT TO CONGRESS STANDARDS FOR SUPERVISION OF PHYSICAL THERAPIST ASSISTANTS (PTAs) AND THE EFFECTS OF ELIMINATING THE PERSONAL PTA SUPERVISION REQUIREMENT ON THE FINANCIAL CAPS FOR MEDICARE THERAPY SERVICES

Summary of Medicare s Request for Information on the Provisions in MACRA which Allow for Implementation of Alternative Payment Models and a Merit-Based Incentive Payment System On September 28, 2015, the

Educational Goals & Objectives Physical and Occupational Therapies are an important part of patient care. The Physical Therapy rotation, under the supervision of the Director of Rehabilitation, is a one

FAQs Med B Student Supervision A frequent question asked of PT and PTA programs has to do with reimbursement of student services for Medicare Part B. Here are some common questions about Med B outpatient

OASIS ITEM (M2200) Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a case mix group, what is the indicated need for therapy visits (total

Physical Therapy I. Policy University Health Alliance (UHA) will reimburse for physical therapy when it is determined to be medically necessary and when it meets the medical criteria guidelines (subject

HOSPICE SERVICES This document is subject to change. Please check our web site for updates. This provider manual outlines policy and claims submission guidelines for claims submitted to the North Dakota